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F0628
D

Failure to Provide Bed-Hold and Transfer Notices at Hospitalization

Elizabethtown, Pennsylvania Survey Completed on 05-22-2025

Penalty

Fine: $21,519
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide required written notifications regarding transfer and bed-hold policies to a resident and/or their representative at the time of hospitalization. Facility policy mandates that before a resident is transferred to the hospital, written information about the facility's bed-hold and return policy must be given to the resident or their representative, and documentation of this notification must be included in the medical record. However, review of the clinical record for a resident with diagnoses including heart failure, anxiety disorder, and chronic kidney disease showed no evidence that bed-hold or transfer notices were provided during two separate hospitalizations. An interview with the Nursing Home Administrator confirmed that the responsibility for sending these notices was assigned to an administrator in training, who did not send them due to a misunderstanding. This resulted in the absence of required documentation and notification for the resident's transfers, as required by facility policy and state regulation.

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